F40607849_12AttachmentEMandatoryCriteriaCertificationForm.pdf

Attachment E

2122-01 ITN RM Statewide Claims and Investigation Services

DEPARTMENT OF FINANCIAL SERVICES

Mandatory Criteria Certification Form

By submitting this form, Respondent acknowledges that the Department will rely on the representations made on this form in making its decision of award. If the Department discovers that any of the information on this form is false prior to the award of the Contract, the Department reserves the right to deem the Respondent non-responsive and cease any consideration of its Response. If the Department discovers that any information on this form is false after the award to the Respondent is made, the Department reserves the right to terminate the Contract and hold the Respondent liable for costs associated with re-procurement.

A Respondent’s failure to provide a “Yes” Certification Answer for each Certification Question below will result in the Respondent being deemed non-responsive.

As the person authorized to sign this form, I certify that the Certification Answers provided below are accurate as to the Respondent.

Respondent Name: _____________________________________________________________________

Authorized Representative: __________________________ __________________________ ______ Printed Name Signature Date

# Certification Question Certification Answer

1. Does the Respondent certify that the person submitting the Response is authorized to respond to this solicitation on the Respondent’s behalf?

__ Yes __ No

2. Does the Respondent certify that it has met the disclosure requirements for Conflicts of Interest as outlined in Section 6 of the

PUR 1001?

__ Yes __ No

3. Does the Respondent certify that it is not on the Convicted Vendor List, Discriminatory Vendor List, or Suspended Vendor List as provided in sections 287.133, 287.134, and 287.1351, F.S., respectively?

__ Yes __ No

4. Does the Respondent certify compliance with Section 9, Respondent’s Representation and Authorization, of the PUR 1001, as modified by section 3.1, Instructions to Respondents, of the solicitation?

__ Yes __ No

5. Does the Respondent certify that it is not engaged in a boycott of Israel or on the Scrutinized Companies that Boycott Israel List?

__ Yes __ No

6. Does the Respondent certify that: (a) it is registered with the Florida Department of State, (b) if awarded a contract under this solicitation, it will register with the Florida Department of State prior to contract execution, or (c) it is not required to register with the Florida Department of State (see applicable sections of Title XXXVI, Business Organizations, chapters 605-623, F.S.)?

__ Yes __ No

2122-01 ITN RM Statewide Claims and Investigation Services

7. Does the Respondent certify that it is not (a) on the Scrutinized Companies with Activities in Sudan List, or (b) on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List?

__ Yes __ No

8. Does the Respondent certify that, if awarded a contract under this solicitation, it will register with and use the E-Verify system as defined in section 448.095(1)(e), F.S., in compliance with section 448.095(2)(a), F.S.?

__ Yes __ No

9. Does the Respondent certify that it has not had a contract terminated pursuant to section 448.095(2)(c), F.S., by a public employer as defined in section 448.095(1)(i), F.S., within the last 365 days?

__ Yes __ No

10. Does the Respondent certify that it has complied with any applicable disclosure requirements in section 286.101, F.S.?

__ Yes __ No